<form id="editAddressForm_45381448" name="editAddressForm" >
    <input type="hidden" name="idx" value="45381448">

        <input type="hidden" name="orderItemId" value="45381448">

    <input type="hidden" name="countryOptIn" id="countryOptIn2" value="US">

        <input type="hidden" name="orderId" value="14146734">

    <div id="addressSection1_45381448" >
      <div >

<div >
    <div ></div>
    <div >
            <input type="checkbox" id="chkBusinessAddress_45381448" name="typeOfAddress" value="H" onclick="addressHelper.addressTypeSelected('45381448');"><label for="chkBusinessAddress_45381448">Business address</label>
        </div>
</div>

        <div >Required field <span >*</span></div>
      </div>

      <div >

        <div id="title_45381448" >

<div >
    <div >Title</div>
    <div >
                <select id="personTitle_45381448" name="personTitle" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0"  widgetid="personTitle_45381448"><option value="" id="personTitle_45381448ph" >- Select Title -</option>

                      <option value="MR/MRS">MR/MRS</option>

                      <option value="MR/MS">MR/MS</option>

                      <option value="MRS">MRS</option>

                      <option value="MR">MR</option>

                      <option value="DR">DR</option>

                      <option value="MS">MS</option>

                      <option value="DR/MR">DR/MR</option>

                      <option value="DR/MRS">DR/MRS</option>

                      <option value="MISS">MISS</option>

              </select>
          </div>
</div>

        </div>


            <div dojotype="dojo.data.ItemFileReadStore" id="relationStore_45381448" jsid="relationStore_45381448" clearonclose="true" url="/gifts/store/BECAjaxIncludeView?storeId=10455&amp;includePage=Snippets/LookupDataJSON.jsp&amp;lookupIdentifier=lookup-relationship"></div>


<div >
    <div >Relationship</div>
    <div >
                <select id="recipientRelation_45381448" name="recipientRelation" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0"  widgetid="recipientRelation_45381448"><option value="0" id="recipientRelation_45381448ph" >- Select Relationship -</option><option value="MOM">Mom</option><option value="DAD">Dad</option><option value="SIS">Sister</option><option value="BRO">Brother</option><option value="HUS">Husband</option><option value="WIF">Wife</option><option value="GPT">Grandparent</option><option value="DAU">Daughter</option><option value="SON">Son</option><option value="ORE">Other Relative</option><option value="SEL">Myself</option><option value="FND">Friend</option><option value="BFD">Boyfriend</option><option value="GFD">Girlfriend</option><option value="CWK">Co-worker</option><option value="CLI">Client</option><option value="PTR">Partner</option><option value="OTR">Other</option></select>
            </div>
</div>

    </div>

      <div id="businessAddressArea_45381448"  >

<div >
    <div >Company name<span >*</span></div>
    <div >
              <div  id="widget_organizationName_45381448" role="presentation" widgetid="organizationName_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="organizationName" type="text" tabindex="0" id="organizationName_45381448" maxlength="24" size="30" aria-invalid="true" aria-required="true" value=""></div></div>
          </div>
</div>

<div >
    <div >Attn. Line<span >*</span></div>
    <div >
              <div  id="widget_businessTitle_45381448" role="presentation" widgetid="businessTitle_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="businessTitle" type="text" tabindex="0" id="businessTitle_45381448" maxlength="30" size="31" aria-invalid="true" aria-required="true" value=""></div></div>
          </div>
</div>

          <input type="hidden" name="organizationNameSave" value="">
          <input type="hidden" name="businessTitleSave" value="">
      </div>

      <div id="homeAddressArea_45381448"  >

<div >
    <div >First Name<span >*</span></div>
    <div >
              <div  id="widget_firstName_45381448" role="presentation" widgetid="firstName_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="firstName" type="text" tabindex="0" maxlength="15" id="firstName_45381448" aria-invalid="true" aria-required="true" value=""></div></div>
          </div>
</div>

<div >
    <div >Last Name<span >*</span></div>
    <div >
              <div  id="widget_lastName_45381448" role="presentation" widgetid="lastName_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="lastName" type="text" tabindex="0" maxlength="24" id="lastName_45381448" aria-invalid="true" aria-required="true" value=""></div></div>
          </div>
</div>

          <input type="hidden" name="firstNameSave" value="">
          <input type="hidden" name="lastNameSave" value="">


<div >
    <div >Additional info</div>
    <div >
               <div  id="widget_additionalName_45381448" role="presentation" widgetid="additionalName_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="middleName" type="text" tabindex="0" id="additionalName_45381448" maxlength="30" value=""><span >e.g., and Family</span></div></div>
          </div>
</div>

      </div>

     <div ></div>

      <div >

<div >
    <div >Street address<span >*</span></div>
    <div >
            <div  id="widget_address1_45381448" role="presentation" widgetid="address1_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="address1" type="text" tabindex="0" id="address1_45381448" maxlength="30" size="35" aria-invalid="true" aria-required="true" value=""></div></div>
        </div>
</div>

<div >
    <div >Apt.,suite, bldg.</div>
    <div >
            <div  id="widget_address2_45381448" role="presentation" widgetid="address2_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="address2" type="text" tabindex="0" id="address2_45381448" maxlength="30" size="35" aria-invalid="false" value=""></div></div>
        </div>
</div>

      </div>

      <div >

<div >
    <div >Country<span >*</span></div>
    <div >
              <select id="country_45381448" name="country" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0" required=""  widgetid="country_45381448"><option value="US">United States</option><option value="CA">Canada</option><option value="AG">Antigua and Barbuda</option><option value="AW">Aruba</option><option value="AU">Australia</option><option value="AT">Austria</option><option value="BS">Bahamas</option><option value="BB">Barbados</option><option value="BE">Belgium</option><option value="BZ">Belize</option><option value="BM">Bermuda</option><option value="BT">Bhutan</option><option value="BN">Brunei</option><option value="CK">Cook Islands</option><option value="CR">Costa Rica</option><option value="CZ">Czech Republic</option><option value="FJ">Fiji</option><option value="FI">Finland</option><option value="FR">France</option><option value="DE">Germany</option><option value="GI">Gibraltar</option><option value="VA">Holy See</option><option value="HK">Hong Kong S.A.R. of China</option><option value="HU">Hungary</option><option value="JP">Japan</option><option value="JO">Jordan</option><option value="KR">Korea, South</option><option value="KW">Kuwait</option><option value="LI">Liechtenstein</option><option value="LT">Lithuania</option><option value="LU">Luxembourg</option><option value="MO">Macau S.A.R. of China</option><option value="MV">Maldives</option><option value="MR">Mauritania</option><option value="MU">Mauritius</option><option value="MD">Moldova</option><option value="NL">Netherlands</option><option value="NZ">New Zealand</option><option value="NO">Norway</option><option value="OM">Oman</option><option value="PA">Panama</option><option value="PY">Paraguay</option><option value="PL">Poland</option><option value="QA">Qatar</option><option value="RO">Romania</option><option value="SM">San Marino</option><option value="SC">Seychelles</option><option value="SG">Singapore</option><option value="SI">Slovenia</option><option value="ZA">South Africa</option><option value="SE">Sweden</option><option value="CH">Switzerland</option><option value="TW">Taiwan</option><option value="TH">Thailand</option><option value="TR">Turkey</option><option value="AE">United Arab Emirates</option><option value="GB">United Kingdom</option><option value="VE">Venezuela</option></select>
          </div>
</div>

<div >
    <div >City<span >*</span></div>
    <div >
             <div  id="widget_city_45381448" role="presentation" widgetid="city_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="city" type="text" tabindex="0" id="city_45381448" maxlength="40" size="35" aria-invalid="true" aria-required="true" value=""></div></div>
        </div>
</div>

        <div id="stateZipSection_45381448"  >

<div >
    <div >State<span >*</span></div>
    <div >
                <select id="state_45381448" name="state" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0" required=""  widgetid="state_45381448"><option value="" id="state_45381448ph" disabled="" >- Select a State -</option>
                <option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AS">American Samoa</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="AA">Armed Forces Americas (AA)</option><option value="AE">Armed Forces Europe (AE)</option><option value="AP">Armed Forces Pacific (AP)</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FM">Federated States of Micronesia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="GU">Guam</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MH">Marshall Islands</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="MP">Northern Mariana Islands</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PW">Palau</option><option value="PA">Pennsylvania</option><option value="PR">Puerto Rico</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="VI">U.S. Virgin Islands</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option></select>
            </div>
</div>

<div >
    <div >ZIP<span >*</span></div>
    <div >
                <div  id="widget_zipCode_45381448" role="presentation" widgetid="zipCode_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="zipCode" type="tel" tabindex="0" id="zipCode_45381448" maxlength="30" size="35" aria-invalid="true" aria-required="true" value=""></div></div>
            </div>
</div>

        </div>
    </div>

      <div >


        <div >

<div >
    <div >Phone number</div>
    <div >
              <div  id="widget_phone1_45381448" role="presentation" widgetid="phone1_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="phone1" type="tel" tabindex="0" id="phone1_45381448" maxlength="20" size="20" aria-invalid="false" value=""><span >000-000-0000</span></div></div>
        </div>
</div>

        <div id="phoneExtArea_45381448" >

<div >
    <div >Ext</div>
    <div >
              <div  id="widget_phone2_45381448" role="presentation" widgetid="phone2_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="phone2" type="tel" tabindex="0" id="phone2_45381448" aria-invalid="false" maxlength="5" size="5" value=""></div></div>
            </div>
</div>

           </div>

            <div >
              <div ></div>
              <div >Recommended for PO Box and wine deliveries</div>
            </div>
        </div>
    </div>

    <div >

<div >
    <div ></div>
    <div >
            <input type="checkbox" id="rbCellPhoneYes" name="phone1Type" value="C"><label for="rbCellPhoneYes">Cell phone</label>
        </div>
</div>

      </div>


    </div>


        <div >
            <div id="emailArea_45381448" >

                  <div id="emailAreaMsg_45381448" >
                      <div >Required field <span >*</span></div>
                      <div >
                          <span >To save your billing address,</span> please provide an email address where we can contact you with order updates and information.
                      </div>
                  </div>

<div >
    <div >Email address<span >*</span></div>
    <div >
      <div  id="widget_email1_45381448" role="presentation" widgetid="email1_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" autocomplete="on" name="email1" type="text" tabindex="0" id="email1_45381448" aria-required="true" aria-invalid="true" maxlength="100" size="35" value=""><span >Enter your email address</span></div></div>
      </div>
</div>

<div >
    <div >Confirm email address<span >*</span></div>
    <div >

        <div  id="widget_logonId_45381448" role="presentation" widgetid="logonId_45381448"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" name="logonId" type="text" tabindex="0" id="logonId_45381448" aria-required="true" aria-invalid="true" maxlength="100" size="35" value=""></div></div>
    </div>
</div>

            </div>
        </div>


    <div id="addressSection2_45381448" >


    </div>
</form>


<form id="orderPaymentForm" name="orderPaymentForm" method="post">
              <input type="hidden" name="langId" value="-1">
            <input type="hidden" name="orderId" value="14146734">
            <input type="hidden" name="notifyOrderSubmitted" value="0">
            <input type="hidden" id="billtoAddressId" name="billtoAddressId" value="">
            <input type="hidden" name="hiddenPromoCode" value="" id="hiddenPromoCode">
            <input type="hidden" name="hiddenCoupon" value="" id="hiddenCoupon">
            <input type="hidden" name="previousOptIn" id="previousOptIn" value="yes">
            <input type="hidden" name="hiddenOptIn" id="hiddenOptIn2" value="yes">
            <input type="hidden" name="countryOptIn" id="countryOptIn2" value="US">

<a name="anchor_payment"></a>
<div dojotype="bec.order.payment.PaymentMethod" id="paymentMethod" jsid="paymentMethod" paypalpreauth="false" paypaltabletremove="false" expresscheckout="false" errormessage="Payment information is missing or invalid." orderid="14146734" widgetid="paymentMethod">
  <input type="hidden" name="policyId" value="" dojoattachpoint="policyId">
  <input type="hidden" name="payMethodId" value="" dojoattachpoint="payMethodId">
  <input type="hidden" name="isPIAddNeeded" value="N">
  <input type="hidden" name="valueFromProfileOrder" value="Y">
  <input type="hidden" name="account" id="account">
  <input type="hidden" name="piAmount" id="piAmount" value="49.90000">
  <input type="hidden" name="remainingAmount" value="0.00">
  <input type="hidden" name="DoExpressCheckout_ErrorCode" value="">
    <input type="hidden" name="DoAuthorization_ErrorCode" value="">
    <input type="hidden" name="tabletDomain" value="">

  <div id="paymentMethodSection" dojoattachpoint="paymentMethodSection">

    <div dojotype="bec.data.ItemFileReadStore" id="paymentMethodStore" jsid="paymentMethodStore" clearonclose="true" url="/gifts/store/BECAjaxIncludeView?storeId=10455&amp;includePage=ShoppingArea/CheckoutSection/Billing/PaymentMethods/AvailablePaymentMethodsJSON.jsp&amp;orderId=14146734"></div>


              <div dojotype="dijit.layout.ContentPane" id="payment2Section" dojoattachpoint="payment2Section"  title="" role="group" widgetid="payment2Section"><!-- BEGIN: GiftCard.jsp -->
<input type="hidden" name="gc_expire_month" value="12">
<input type="hidden" name="gc_expire_year" value="2014">
<input type="hidden" name="gc_policyId" value="11210">

<div id="giftCardSection" dojoattachpoint="giftCardSection" >
  <div >
       <span >Redeem a Gift Card</span>
  </div>
  <div >
    If your order exceeds your Gift Card balance, please enter additional payment information.
  </div>
  <div >
    <div >Gift Card Number</div>
    <div dojoattachpoint="_wrapper"  widgetid="gcAccount"><div  id="widget_gcAccount" role="presentation"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" name="GiftCardNumber" type="text" tabindex="0" id="gcAccount" size="22" maxlength="20" aria-invalid="true" value=""></div></div>
<input type="hidden" name="GiftCardBrand" id="GiftCardBrand" value="" dojoattachpoint="_cardType"></div>
  </div>

  <div >
    <div >PIN*</div>
    <div  id="widget_gcPin" role="presentation" widgetid="gcPin"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" name="GiftCardPin" type="text" tabindex="0" id="gcPin" size="6" maxlength="4" aria-invalid="true" aria-required="true" value=""></div></div>
  </div>

  <div >
      <a href="#checkGiftCardBalance" onclick="return false;" dojoattachevent="onclick: showGiftCardBalancePopup">
        Check Gift Card Balance
      </a>
    </div>

    <div >*scratch off the covered section on the card back or for an eGift card, refer to your email.</div>
</div>
</div>


    <div >Payment Method:</div>


      <div dojotype="dijit.layout.ContentPane" id="payment3Section" dojoattachpoint="payment3Section"  title="" role="group" widgetid="payment3Section"><!-- BEGIN: PayPal.jsp -->

<div id="paypal-section" >
  <div >
    <div  role="presentation" widgetid="paymentType-PayPal"><input name="paymentType" type="radio"  data-dojo-attach-point="focusNode" data-dojo-attach-event="onclick:_onClick" value="on" tabindex="0" id="paymentType-PayPal"></div>
  </div>
  <div >
    <label for="paymentType-PayPal"><span ></span></label>
    <a href="#whatIsPayPal" id="whatPaypal" >What is PayPal?</a>
  </div>
</div>

<!-- END: PayPal.jsp --></div>
      <!-- payPalToken:  -->
    <div id="payment1Section" >
      <div dojotype="dijit.layout.ContentPane" id="paymentInput" dojoattachpoint="paymentInput"  title="" role="group" widgetid="paymentInput"><!-- BEGIN: CreditCard.jsp -->
<div >

    <div >
      <div  role="presentation" widgetid="paymentType-CC"><input name="paymentType" type="radio"  data-dojo-attach-point="focusNode" data-dojo-attach-event="onclick:_onClick" value="on" tabindex="0" id="paymentType-CC" aria-checked="true"></div>
    </div>

  <div >
    <label for="paymentType-CC" ><div id="cardTypeImg" ></div></label>
  </div>
</div>
<div id="paymentCreditCard" dojoattachpoint="paymentCreditCard" >
  <div >
    <div >Card Number</div>
    <div dojoattachpoint="_wrapper"  widgetid="clearTextAccount"><div  id="widget_clearTextAccount" role="presentation"><div ><input  value="Χ " type="text" tabindex="-1" readonly="readonly" role="presentation"></div><div ><input  data-dojo-attach-point="textbox,focusNode" type="text" tabindex="0" id="clearTextAccount" size="23" maxlength="30" aria-required="false" aria-invalid="true" value=""></div></div>
<input type="hidden" name="cc_brand" id="cc_brand" value="" dojoattachpoint="_cardType"></div>

  </div>
  <div >
    <div >Expiration Date</div>
    <div dojotype="bec.data.ItemFileReadStore" id="expirationMonths" jsid="expirationMonths" clearonclose="true" data="bec.order.payment.Expiration.getMonths()"></div>
    <select id="expire_month" name="expire_month" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0" required=""  widgetid="expire_month"><option value="" id="expire_monthph" disabled="" >- Month -</option><option value="01">01 - Jan</option><option value="02">02 - Feb</option><option value="03">03 - Mar</option><option value="04">04 - Apr</option><option value="05">05 - May</option><option value="06">06 - Jun</option><option value="07">07 - Jul</option><option value="08">08 - Aug</option><option value="09">09 - Sep</option><option value="10">10 - Oct</option><option value="11">11 - Nov</option><option value="12">12 - Dec</option></select>

    <div dojotype="bec.data.ItemFileReadStore" id="expirationYears" jsid="expirationYears" clearonclose="true" data="bec.order.payment.Expiration.getYears({min: new Date(), displayYears: 12})"></div>
    <select id="expire_year" name="expire_year" dojoattachpoint="focusNode,valueNode,textbox,comboNode,containerNode" dojoattachevent="onchange: _selectOption" tabindex="0" required=""  widgetid="expire_year"><option value="" id="expire_yearph" disabled="" >- Year -</option><option value="2014">2014</option><option value="2015">2015</option><option value="2016">2016</option><option value="2017">2017</option><option value="2018">2018</option><option value="2019">2019</option><option value="2020">2020</option><option value="2021">2021</option><option value="2022">2022</option><option value="2023">2023</option><option value="2024">2024</option><option value="2025">2025</option></select>
  </div>
</div>
<!-- END: CreditCard.jsp --></div>
    </div>
  </div>
</div>
<!--  BEGIN Partner Feed PartnerFeedOrderPaymentForm --><!--  END Partner Feed PartnerFeedOrderPaymentForm -->
          </form>


